Thanks for signing up! You might also like these other newsletters:

You don’t want your child with psoriasis to suffer from painful itching and inflamed skin. But addressing the sadness and social isolation they may feel is just as important. You’ve probably noticed your child feeling self-conscious: how do you help them?

Join us for a comprehensive discussion about raising a child with psoriasis. From how psoriasis begins to how it is treated, our guests will educate you on every aspect of this difficult condition. You’ll learn how to help your child express negative emotions about their skin, and how to educate friends and family and school staff so that they can help your child cope with psoriasis. And you’ll hear about the steps being taken to ensure that current medications are truly safe for children.

As always, our expert guests answer questions from the audience.

Announcer: Welcome to this HealthTalk webcast. Before we begin, we remind you that the opinions expressed on this webcast are solely the views of our guests. They are not necessarily the views of HealthTalk, our sponsors or any outside organization. And, as always, please consult your own physician for the medical advice most appropriate for you.

Now here's your host, Ross Reynolds.

Ross Reynolds: Hello, and thank you for joining us for Helping a Child with Psoriasis. I'm your host, Ross Reynolds.

Watching your child with psoriasis suffer from painful itching and inflamed skin is heart-breaking, but seeing the sadness and social isolation they may feel is even more devastating. You have probably noticed your child with psoriasis feeling self-conscious. How do you help them?

During this webcast our expert guest will discuss not only the physical effects of psoriasis on a child or young adult, but also the emotional fallout, especially at a time when their social development is so crucial. You will also hear expert strategies for helping your child cope with pain inside and out.

Joining us is Dr. Albert Yan. Dr. Yan is the chief of pediatric dermatology at Children's Hospital of Philadelphia. He also directs the pediatric dermatology fellowship training program. Welcome, Dr. Yan.

Dr. Albert Yan: Thank you for that kind introduction, Ross. I appreciate the opportunity to be here to today to talk about this important skin condition.

Ross: We are lucky to have you with us.

To start out with, how common is childhood psoriasis, and what is the youngest age that it will appear?

Dr. Yan: Psoriasis is one of the more common skin conditions that we encounter in the United States, and it affects about one to two percent of the general population. And while it can happen to people of any age, it's actually most common after puberty, and the peak ages are during the pre-college years, typically between the late teens and early 20s, and what some people have called the pre-retirement years between the late 50s and early 60s.

If you look at children specifically, about a quarter of all psoriasis cases occur in kids under 16, and about ten percent of those occur below ten years of age, and it's pretty uncommon in the very youngest children, with only about two percent in kids under two. And while there are some infants who are born with psoriasis, that's exceedingly rare.

Ross: Is psoriasis different in any way for children and adolescents than it is for adults? For example, do children get a certain type of psoriasis more often than adults, or does it tend to be less severe?

Dr. Yan: The actual skin lesions of psoriasis are pretty similar at any age, and they typically look like scaly, red and white areas of skin. That being said, infants, when it occurs at that age, tend to get a form of psoriasis known as napkin psoriasis or diaper psoriasis, and that typically looks like a red, scaly diaper rash that is poorly responsive to conventional diaper rash treatment. So these children oftentimes go through multiple different courses of treatment until they are later diagnosed with that type of psoriasis.

Older children are more likely to develop a kind of psoriasis that we commonly refer to as guttate psoriasis. And in this condition the lesions of psoriasis look like little drops of the red, scaly skin that's typical of this condition as opposed to some of the larger plaques that we see more commonly in adults that usually occur on elbows and knees and other contact surfaces.

When psoriasis develops in kids, it is also more likely to be linked to arthritis, although fortunately, only about five percent of those who have the skin findings of psoriasis will later go on to develop arthritis. And finally, kids who get psoriasis are also more likely to have other family members with psoriasis, as psoriasis tends to run in families as a hereditary disorder.

Ross: Does it tend to be more or less severe than when it comes on with adults?

Dr. Yan:It varies, and the degree really varies depending on the actual individual. So some kids can have fairly severe psoriasis that rivals that seen in adults, but many of the kids that we treat early on have milder psoriasis that can later remit from time to time.

Ross: What are some of the unique issues that your young patients with psoriasis face, Dr. Yan?

Dr. Yan: As you might suspect, there is significant emotional fallout that can occur in kids who get psoriasis. It is a terrible time to be different from others, and as kids enter school, their self-esteem is developing, and they want to be like all the other kids. They want to feel a sense of belonging, and kids this age happen to be very good at identifying qualities that make each other different. And they can tease each other about these, and they make some false assumptions, for instance that psoriasis is contagious or that it's related to dirt, which are clearly myths. Any chronic disease at this age is likely to be stressful, and it is made even more so by a disease that's as visible as psoriasis.

Ross: How about the treatment for children? Is it more complicated than it is for adults?

Dr. Yan: The treatment of psoriasis raises some special issues. It is a period of rapid physiological and psychological growth and development, so any treatments that are selected have to take those factors into account because we clearly don't want to interfere with that normal development. So the role of your pediatrician, family doctor and dermatologist is really to help you and your child navigate the risks associated with any possible treatment options.

Ross: Now, some of these medications are really powerful drugs - the steroids, methotrexate and the biologic therapies. What kinds of challenges do they present when you are dealing with children?

Dr. Yan: Well, we have to take certain, specific factors into account, and age is one important factor. Infants, for instance, have a large amount of body surface area relative to their weight, so any topical medicines you apply are more likely to be absorbed systemically into the blood stream and can cause side effects if overused. In infants, medicines with lower potency are therefore usually selected and used for shorter periods of time.

Types of involvement (the location of the psoriasis) are also important. You don't want to apply thick greasy ointments to the scalp or use things that affect the kids in terms of how they feel, so we oftentimes substitute lotions and liquid medications and medicated shampoos for the scalp and use creams for hands and feet and use ointments where possible on other sites. And then the face areas that require lower-strength medications, we have to select appropriate medications for these areas because the skin is much thinner at these anatomic sites. And involvement of the hands and feet can be actually quite debilitating because kids in school need to use their hands to write and draw and interact, to play sports. They use them for everything. And so these areas often require more aggressive therapy when these areas are also affected.

And then the degree of (psoriasis) involvement also influences the kinds of treatments you can offer as dermatologists or specialists. Localized disease on an elbow or knee, for instance, can be pretty easy to control. If you have one localized area, you can apply a topical medication of appropriate potency and get that under control reasonably quickly. But more widespread disease - say a child who has more than 20 percent of the body surface area involved - may require something like ultraviolet light therapy, or a child with joint disease may require systemic agents.

And finally, pediatric psoriasis is not uncommonly triggered by infection like group A strep, which are also commonly known to cause strep throat. So in those cases, we have the capability of using antibiotics against strep, and sometimes that can actually help modify the course of the disease.

Ross: When you are talking about dealing with psoriasis with an adult, you need to set some treatment goals, but how does setting treatment goals work when you are talking about a child or a young adult?

Dr. Yan: The goal of treating psoriasis really has to be understood as control rather than a cure because psoriasis is chronic disease, and we don't have a cure for it, but we can usually control it reasonably well. So when we decide on treatment plans that depend on the severity and extent of disease, there are a few things we take into account first with regard to children.

In kids the most important factor when selecting any treatment is really safety. You don't want to make the treatment worse than the disease itself, and so you have to select the safest treatment options available. That being said, you also need to find a treatment that will be effective. The kids and their parents want you to pick something that actually works and that the child will respond to reasonably well so that the child and family don't feel that their time or effort is being wasted.

And then third, I also warn families up front that while we try to recommend the safest and most effective treatment available, there is also some trial and error involved since every child we treat is different. And fortunately most children will respond to the topical agents using lower potency agents on the thinner skinned areas like the face or intertriginous areas (an area where opposing skin surfaces touch and may rub) like the underarms or the private areas, and then we can have the liberty of using more potent agents where the skin is much thicker, say the arms and legs or hands or feet.

And there are a variety of topical agents available that are fortunately reasonably effective. They range from topical steroids, topical vitamin D or vitamin A analogs, topical calcineurin inhibitors (tacrolimus and pimecrolimus), which have been used primarily for atopic dermatitis but which have some clinical effect on psoriasis, and even older compounds like tar compounds can be used in the younger kids who can tolerate it. But for the more severe disease, we oftentimes have to think about more systemic agents.

But the bottom line is you don't want to make the treatment plan too complicated, and it's very easy when you are dealing with a child with psoriasis to prescribe six or seven different things to do for a patient and the family, and although our families are often highly sophisticated, if you make the plans too complicated, even these sophisticated families have a hard time following recommendations, so keeping it simple is best.

Ross: Now, with an adult it's you, the doctor, and the patient, but you have got three people involved when you are dealing with a child, you and the patient and the parent. How does coming up with a treatment plan vary when you've got three players?

Dr. Yan: That's exactly right, and that's the challenge of doing pediatrics in general. I think that we have to work together with both the child and the parents to make things work. And depending on the age of the child, and certainly with the infants, the younger kids, it's actually a fairly straightforward process of educating the parents, and the younger kids usually will tolerate most topical agents.

And the older kids generally want a little more independence, and they want things that won't make them look excessively greasy, and won't make them feel greasy and slippery, and so with school-aged kids and especially teenagers, we have to engage them in terms of finding treatments that they are willing to use and that they find doable. The parents oftentimes act as the gatekeepers and want to make sure that whatever we recommend is safe, while oftentimes their teenagers are trying to get the most effective, fastest-acting agents possible to make them look and feel better. So we often have to compromise in those situations and find something that's reasonable for all parties involved.

Ross: How about light therapy? Does light therapy help when you are working with kids and adolescents?

Dr. Yan: Well, certainly with the younger kids it's more difficult, because it's hard to have a very young child sit in a light box, and in those cases where it's really necessary, we have the parents work with them in the light box when necessary. But I think light treatments can be a wonderful alternative, especially in kids that have been on chronic topical therapy. The other advantage is that UV phototherapy is often remittive, meaning that if you treat a child with UV (ultraviolet) therapy, they can oftentimes stay clear of disease and off therapy for a period of time afterwards, not requiring any treatment. Eventually though, because it is a chronic disease, it will recur, but they oftentimes have this break in between episodes. Most other treatments are suppressive, so the disease often recurs once you stop treatment, so that's the big advantage of UV therapy when it's appropriate to use on a child.

The problems with light treatments are that, number one, it requires a family to come in two to three times a week for treatment, which can be challenging. And second, insurance may or may not actually cover their treatment with phototherapy, and that's an issue that occurs with a number of different insurance plans. And then, third, there are relatively few centers where light treatment is now available, meaning that families oftentimes have to travel great distances sometimes to receive treatments.

Some people suggest maybe trying to use a tanning salon because they are certainly more common than phototherapy centers. The problem with tanning salons are that they usually use mostly UVA light, and the type of phototherapy that we tend to use medically for children who have psoriasis usually involves more UVB phototherapy. That's the one that's most effective for psoriasis, and that's not what's typically offered in a tanning salon. So they are not an ideal setting for psoriasis treatments for children.

And then the one last thing is that chronic UV exposure may somewhat increase the risk of later skin cancer, and that's always something to take into account.

Ross: There are other special concerns for children who are taking some of the heavier drugs, the steroids, the methotrexate, and the biologics? And how effective are they, and what are the specific safety concerns for children?

Dr. Yan: Well, the systemic (affecting the entire body) agents as a class are generally very effective especially for moderate and severe or more widespread psoriasis. The problems again revolve around safety. These agents while oftentimes quite effective are fraught with certain types of side effects that we have to be aware of. First and foremost, I personally avoid oral steroids in my patients with psoriasis. My clinical experience has been that oral steroids may provide short-term relief, but children become dependent on the steroids. They can work in the short term, but I have also seen quite a number of children who have severe flares of their psoriasis when they come off the steroids, and they oftentimes end up worse than they were before they went on treatment.

Topical treatment steroid medications can work fast and, if used judiciously, rarely show side effects although we do monitor for skin signs such as thinning, stretch marks, or slower growth and hormone suppression when used more aggressively.

As for the other agents, methotrexate has had a long track record of use in adults and also in kids. And in kids we have great experience with a number of other diseases like pediatric arthritis and types of tissue diseases, and it works well for psoriasis too, so long as proper monitoring for liver and lung function is performed.

As for the biologic agents, they're a hot new class of drugs that hold a lot of great promise for the management of psoriasis. They are a heterogeneous group of agents that affect parts of the inflammatory cascade that is involved in generating psoriasis. And they are generally not approved for use in children with the exception of etanercept or Enbrel. And this agent is approved in children (with) juvenile idiopathic rheumatoid arthritis and is being studied for its effects on pediatric psoriasis as are a few of the other agents [no biologic agent is yet FDA-approved for pediatric psoriasis]. So I think this class of drugs has great promise for treating moderate to severe psoriasis with potentially few side effects and actually great efficacy. But longer term studies are going to be necessary because there are some theoretical concerns with regard to an increased risk of lymphoma and, shorter term increased risks of certain types of infections when using these agents.

Ross: Are there other concerns besides lymphoma and infections when we are talking about the side effects and long-term effects for things like methotrexate and the biologics?

Dr. Yan: There are a whole host of things that we need to watch for. In the short term, we can help to avoid side effects by monitoring for them with appropriate blood work, checking blood counts, which can be decreased with using things like methotrexate for instance. Some of the biologic agents can also affect blood counts, and so monitoring these can clue you in to early changes that can then help you adjust the dosage or temporarily stop treatments as needed or switch agents altogether where necessary.

Ross: When we are adolescents, our bodies are changing, our hormones are raging - does psoriasis, or any of these treatments we have been talking about, affect those things? Or on the other hand, do hormones play an effect on developing psoriasis?

Dr. Yan: I think that's a really interesting question. I don't know that there is specific data on this, but certainly it seems as if hormones would play a role, and I think that that's why we see such an increase in the incidence of psoriasis among children after puberty and later on in adulthood. And I think it's also why we tend to avoid overuse of certain medications, like steroids, which can affect other hormones which can affect overall growth if these medications are used to excess.

Ross: As children grow into adolescents and then grow into adults, what typically happens to their psoriasis? Do they grow out of it? Does it continue to affect them?

Dr. Yan: Well, that's a great question, and it is one that families ask a lot, and they want to know if things will get better. Will they be able to get control of their psoriasis? And in general I think we can have a reasonably optimistic outlook for most kids with psoriasis because we can usually control it with appropriate therapies. The issue is: What's going to happen with their psoriasis later on? And that's a question that we can't completely answer, because it's hard to predict since every child is different. Some people can go into an extended remission after some initial treatment, and it may not show up again for some years, while others have sudden flare-ups now and then.

And the bottom line is that psoriasis is a chronic disease, and although it can go into remission from time to time and often improve during periods of time, what I can tell families is that we can expect occasional flare-ups, we can control the condition, and that we oftentimes see some seasonal improvements in the summer and some flares during the winter for most.

Ross: Dr. Yan, let's talk a little bit more about the psychological impact that psoriasis can have on a child or a teenager. As you mentioned, one concern that most children of any age have is to fit in with their peer group. Kids don't like standing out or being different. How does that fear impact kids with psoriasis?

Dr. Yan: Well, as you might expect, Ross, this is a big deal for kids. Psoriasis is such a visible disease oftentimes that it's hard for affected kids to hide their condition, and this can make kids feel even more isolated and have long-term effects on their self-esteem, especially if they have the disease early and then continue to have it as a chronic condition through adolescence and then on into adulthood. Fortunately, most kids are up to the task and overcome these obstacles to become well adjusted and successful adults. And what I think helps most is having kids become educated about their disease and develop realistic expectations so that there isn't a lot of mystery surrounding their condition.

And so there are a number of things that I try to emphasize with them when I counsel patients and families. And one is that psoriasis is a chronic disease, and it is not going to go away anytime soon but that we can usually manage it quite effectively, that it's unpredictable, and that flares can occur for no apparent reason, and oftentimes it's not the fault of the child that they are having a flare or that they have the condition itself, and they shouldn't blame themselves for having psoriasis.

At the same time, they can avoid certain aggravating factors, things that will make their psoriasis worse, like rubbing and scrubbing. Many parents who are well-intentioned will see a spot of psoriasis that's flakey or scaling on the scalp or other areas, and they try to scrub those scales off and make it less conspicuous and in the process may aggravate the condition because it may bring out more psoriasis. This is a phenomenon referred to as the Koebner phenomenon (the Koebner phenomenon, also called the isomorphic response, refers to the appearance of psoriasis at a site of injury).

Psoriasis also isn't contagious, and I think that's a stigma that some kids carry especially early on thinking that it's a contagious condition and try to minimize physical contact, and that's the opposite of what they actually need. And they need to understand that it's not a contagious condition, and that's one of the things they can educate their friends about so that they don't feel so isolated.

And then lastly, I think the issue for many of the kids is: Should they keep their condition a secret or not, and should they leave their skin covered and keep that secret as long as they can, or to uncover it and let people know about it? And I think that has to be a personal decision, and I try to support the child and family in whatever ways they need, depending on which approach they feel most comfortable taking at that particular time.

Ross: What about self-esteem? What do you tell teenagers about maintaining their confidence and a healthy sense of self when their skin is covered with psoriasis?

Dr. Yan: I think the main difficulty here is that teenagers tend to universalize, and they feel that they may be the only ones going through what they are going through. So when they suffer from psoriasis, they oftentimes feel they are the only ones. And you can provide them with education to give them the statistics about how common this condition is, you can provide them with other avenues to meet other kids who have the condition so that they know they are not alone and that they can feel part of a larger community. And they also have to understand that psoriasis doesn't define them and that the disease is not who they are. They have so many other qualities and things going for them, and they should emphasize the qualities that make them who they are, and that provide them with a more positive outlook.

Ross: What are the ways that young people with psoriasis can break out of that isolation and that feeling of being alone?

Dr. Yan: I think there are a number of different support groups that are helpful, and I think the bottom line is that kids do best when they feel like they are part of a larger community, that they belong, that they are part of a larger network of family and friends and counselors and teachers. And support groups can be helpful because the kids can know that they are not alone, and there are a number of psoriasis support groups. There are psoriasis camps.

There are a number of organizations like the American Academy of Dermatology, and the National Psoriasis Foundation which has copious resources to help provide this type of support. They have lots of information with regards to these support groups and camps and other group activities like the Camp Discovery program. And these resources are available on their Web site and are really wonderful. I think these are some of the opportunities they have to really become part of a network.

Ross: Kids can be pretty brutal with their teasing to other kids who are different from them. How do you help your patients deal with the teasing they might face?

Dr. Yan: Well, that's another great question, Ross. It's something that I think as pediatricians, we all deal with on a fairly regular basis because kids tease other kids, not just because of psoriasis. They tease kids about their hair color or what they are wearing. And kids, especially at school age, can be mean sometimes.

I think one of the best ways when dealing specifically with psoriasis is to empower the kids by teaching them about their disease. Once they know what psoriasis is, what to expect from it, that they are not alone and that they have friends and family who are there to support them, most kids can weather any teasing. And I think if they can speak articulately about psoriasis because they know about their disease and they can address the concerns or fears of their schoolmates or friends; they're empowered to really take charge of that, and they can deal pretty effectively with that kind of teasing.

Ross: Dating when you are a teenager is nerve-wracking enough, but how about for people with psoriasis? What advice do you have for teenagers as they enter the dating world with psoriasis?

Dr. Yan: This is another sensitive area, and kids who have psoriasis may be reluctant to date because they feel that they have to explain their disease or worry that they might experience rejection once people find out that they have psoriasis. They may stress about whether to tell potential dating interests up front about their psoriasis or wait and feel guilty about keeping a secret.

And while some kids are very open about their disease up front, I don't think there is anything wrong with kids who feel that they would rather wait until their boyfriends or girlfriends get to know them better first, that psoriasis doesn't define them, and so on a first date you don't necessarily tell your date everything about you. And just as it can take time for people to get to know you and what your interests are, what your musical tastes are, your child can take the time to decide on when to let their girlfriend or boyfriend in on their condition, which is certainly a very personal matter.

They also need to understand that if a relationship doesn't work out, it's not necessarily related to their psoriasis, and psoriasis isn't necessarily to blame. It may just be that they didn't click or that they didn't have enough in common and that they need to move on and make new friends and create new relationships. But I think it's very easy for kids who have psoriasis to become depressed and blame their condition because it's such a visible part. They need to be reassured that that's not necessarily the case and that there are other things that are part of being a normal teen or adolescent that can also come into play.

Ross: Dr. Yan, do you have any advice for parents who want to do what they can to lessen the emotional impact of psoriasis on their kids?

Dr. Yan: Parents love their kids unconditionally no matter what, and that in-and-of itself I think is a great source of comfort for kids, even if the kids might not show it sometimes. And I think some of the same guidelines that I just outlined would certainly be helpful for parents. I think for the younger kids especially.

For a number of kids with visible chronic conditions, like alopecia areata (a condition in which hair is lost from areas of the body) or psoriasis, some of the parents take the initiative to speak to the principal and the schoolteachers to apprise them of the situation and educate them about the condition, oftentimes bringing in the child so that they can take part in that education.

And then the teacher can, at their discretion, educate the class about the condition, and bring out of all of these issues up front at the beginning of the year so that the child isn't then having to deal with questions and secrets throughout the year, and they can then move on to just being a child. So I think the education is really a major point that I like to emphasize.

The parents also need to emphasize patience with the kids, because the kids oftentimes want their skin disease managed or gone yesterday, and some of these treatments do take time, especially since we want to use safer treatment options.

And the kids need to understand that they have a social support network that they can rely on, because if they feel isolated, they need people to talk to. And sometimes the younger kids certainly will focus on talking to the parents, but the parents also need to understand that as the kids grow up and become teenagers, they may choose not to always confide in them and will sometimes talk more with friends or counselors at school, and that they need to be comfortable understanding that they have a larger network that they may use to rely on.

And the parents can certainly help them with finding the resources like the support networks, the camps, the support groups, getting them on the Web to find out more about the condition, and also helping to make sure that they are getting reasonable information by vetting it and making sure that it's realistic. And I think it's important that parents understand that they need to let their kids be angry or sad or confused at times and just to be there to help them get through these various situations, because kids are very resilient, and they will rebound if they know that they have their support systems there.

Ross: Do children with psoriasis tend towards substance abuse to deal with their illness, or are they about the same as other teens with regard to that?

Dr. Yan: Well, it's known that in adults, substance abuse, alcohol use and smoking have all been linked to psoriasis and can aggravate it (psoriasis). And part of that may be it's the reverse, that the psoriasis may lead them, in some cases, to that (substance abuse). I don't think adolescents are much different in this regard, so I think that these are certainly risks that have to be kind of kept in mind and that as parents, you need to watch out for substance abuse in these situations.

Ross: Smoking is a bad idea for everyone, but how about kids with psoriasis? Is it worse for them?

Dr. Yan: There is some data to suggest that people who have psoriasis will have worse psoriasis if they smoke, so that's another reason and another factor to help kids not take up smoking in the first place.

Ross: What about anti-depressants or anti-anxiety medicines, are they helpful when trying to treat the psychological impact on children and young adults with psoriasis?

Dr. Yan: Well, I don't recommend these agents up front. For those who are under unusual stress or who experience depression or anxiety about their disease, these agents really can be helpful when used under the supervision of either their primary care physicians or a mental health professional. So I think there is definitely a role for these, but I think that in most cases, you can certainly manage the condition with appropriate medical treatments, and that oftentimes, the feelings of depression or anxiety are related to having a skin disease, and if you control the skin disease more effectively with these various treatment options, some of those feelings will actually abate and subside.

So I think that it has to be a multidisciplinary approach. If you notice your child is having some issues with regards to feeling unusually sad or depressed or anxious about things and you think that it may be related to the condition, make sure that you get them into treatment for their skin disease. Have them see their primary care provider or a specialist or a dermatologist. And then as their skin condition starts to improve, assess whether or not their mood also improves over time. And if it does, then you don't need to go that route.

But if your child still is suffering, then definitely get some additional help and support. These really can be good, transitional medications, short-term use for a period of time to get them through until they are better able to cope.

Ross: We have an e-mail question for you, Dr. Yan, from Charley in Tacoma, Washington who writes, “My nine-year-old has psoriasis, and it's getting to the point that every time a new school year begins, it's harder and harder to get my son to get his immunizations shots. He breaks out with a large patch of psoriasis around the point of the shot. Do you know if this is caused by any allergic reaction he is having with his shots, or is this something he will just have to suffer through with his psoriasis condition?”

Dr. Yan: I think that's an excellent question. And as we alluded to earlier, there is a phenomenon known as the Koebner phenomenon, and it's a description of a condition that happens in people who have psoriasis where when the skin is injured or inflamed, whether that involves physically scratching it or getting a scrape or a cut, getting a poison ivy rash or an immunization, for instance. At the site where the inflammation or injury occurs, you can cause psoriasis to appear. And there are ways of managing that if you know that it's likely to happen.

Certainly if you know that your child is scheduled for an immunization, what you can do is speak with your pediatrician or primary care doctor or dermatologist about what types of treatments you can do immediately after the immunization is given in an effort to block that reaction from happening. And oftentimes what I will do in some of our patients who give me that type of history is to have them use a topical medication for their psoriasis immediately after they get their shots in an effort to abate or prevent that reaction from occurring. And as long as you use a reasonable, lower-potency medication, something that's anti-inflammatory but that won't interfere with the antigenic reaction, you shouldn't have a problem. The topical medication should not have a significant impact on the effectiveness of the immunizations.

Ross: Leslie from Topeka, Kansas writes, “I have a six-month-old that recently started to get rashes around his nappy area, and I was first told he possibly only had a nappy rash. But recently the coloring of the rash is really red and shiny. My husband does have a history of psoriasis in his family, but according to him, it occurred much later in life. Is it possible for a newborn to have psoriasis?”

Dr. Yan: Well, while it is rare, it is indeed possible. And as we talked about earlier in the program, napkin psoriasis is a type of presentation that can be an early marker for psoriasis. Now, having one family member, a parent who has psoriasis, does increase the risk of having a child with psoriasis. That risk is estimated roughly to be around 15 percent. It’s not definite that the child is going to have psoriasis, but it does certainly raise your suspicions that that could be the case here.

Diaper rashes, or nappy rashes, are so common in kids who wear diapers that you really have to rule out the other causes first. And you can do that over a relatively short, reasonable period of time by using conventional diaper rash treatments, using barrier creams and ointments that are available over-the-counter. Make sure that you treat any secondary infections which usually occur with yeast but occasionally can be complicated by strep, streptococcus or group A strep. And if you address these particular concerns, and you are still dealing with a chronic recurrence of nappy rash or diaper area rash, then you really do have to think about the possibility of psoriasis. Using some psoriasis treatments at that point and seeing if they are helpful can sometimes be diagnostic and can help you make that diagnosis. So I think that there is still a little work to be done before you can be sure that it is indeed psoriasis, but it is certainly, I think, reasonable to think about that on the potential diagnosis list.

Ross: Janet from Nashville, Tennessee writes, “My daughter has scalp psoriasis, and school dance seasons are coming up. She is looking to stop taking tar-based shampoos because of the strong odor. Are there any substitutions she can take in place of tar-based shampoos?”

Dr. Yan: That's another excellent question. And I think again it speaks to the fact that you have to find the right type of treatment for each individual child, and that may change as the child gets older. And while tar-based shampoos are commonly used, especially in the younger kids, there are a whole host of other options that you can definitely consider. One of these would be the salicylic acid-based shampoos that are available over-the-counter. They are usually clear, and they don't have a strong tar odor associated with them. And these are very effective at descaling the scalp and making the psoriasis less conspicuous.

There are also some prescription-strength options as well that can be used, and these range from using medicated shampoos, which might include a very low-potency topical steroid that, used intermittently, can also help control the psoriasis and descale the scalp. There are also foams and liquid medications that can be applied to the scalp in lieu of shampoo, and these can be helpful and less conspicuous and not associated with the tar odor of the traditional tar shampoos.

And then lastly there are some oils that can be used and applied to the scalp on a nightly basis, used once in a while when needed. They don't have a strong odor associated with them, and when left on overnight and then washed out in the morning with a conventional shampoo, or one of these other agents that we have talked about, can help descale the scalp. These don't necessarily need to be used every day. It can be used sometimes just a couple times a week to maintain the benefit. So, yes, there are definitely options that you can consider aside from the tar-based shampoos.

Ross: This e-mail comes from Beverly Hills, California. “How do I explain to my child that that he might need to have an injection to treat his psoriasis?”

Dr. Yan: That can be a problem, especially with some of the younger kids, and I think most of us have at least some degree of needle-phobia, and that does improve with time. Depending on the type of treatments, some injections certainly hurt more than others, and it partly depends on what treatment you are using. There are certain things that can be done ahead of time to make the child feel more comfortable when you are giving an injectable medication. One of these is to use a topical numbing cream that you apply to the skin for about half an hour to an hour. And these agents - the way that I explain it to the kids - look like cake icing, and you apply about a teaspoon worth or a little bit more to the area where the injection is to be given, and you do so about half an hour to an hour ahead of time.

And what that does is it numbs the skin fairly nicely so that you can really take the edge off of the injection. And some kids note after the cream has been on that they don't even feel the injection, and what they really feel is just when the medicine is being pushed in underneath the skin, and some kids don't even feel that much. So I think that can be a real help for the families where the kids are feeling self-conscious or worried that it's going to hurt. Because I think that's the main reason that kids don't like needles is that they are worried about the pain. And whatever you can do to help decrease that will help.

The other technique that I oftentimes use in the office setting, which can be easily done at home, is to have a distraction. And this works especially well for the younger kids. So if you have a TV program on that they like and that they get into, or you put in a movie on a small DVD player, which is what we do at the office setting for procedures that we think might be painful for the kids, these distractions actually have been shown in studies to be quite effective at reducing pain sensations. And so if you can set that up ahead of time and develop a routine where they know that they are going to have this in place, you can start the video or start the show, have the cream in place, and then when you do the shot, they feel less discomfort.

And I think once they realize that after the first set of injections that it's not so bad, it actually gets easier. And when they start seeing their disease improve, many of them stop worrying so much about the pain and get much more invested in getting their skin condition better. And that I have seen more so with our adolescents who may have some needle-phobia, but when they realize that their skin condition actually gets significantly better when they're using it, they are all for getting it, and they look forward to getting the injections to keep their skin under better control.

Ross: We got this from Brett in Sacramento, California: “I am 19 and have severe psoriasis on my genitals. How am I supposed to have an active sex life? Any advice would be helpful.”

Dr. Yan: That can be a very difficult problem, and there are certain areas of the body that we certainly try to treat more aggressively, areas that are of significant importance to a particular individual like the hands or feet or the genital areas. And in these cases, sometimes we do tend to be a bit more aggressive with treatment. And while we may normally think about a limited geographic area on the body as being appropriate for a topical treatment, sometimes we may need to think about alternative, nonsteroidal agents like some of the calcineurin inhibitors. We can also consider using the topical vitamin D analogs.

But if these have been tried and aren't as effective, then we have to think about using things like the systemic agents, like biologic agents which can be helpful at controlling the disease better. And so we try to individualize these treatments for those who have specific needs or issues. I would certainly start with some of these nonsteroidal topical agents and see if they can be effective.

It involves some trial and error and being patient, but try a few different things sometimes in combination. And then if those don't work, try some of these biologic agents and taper them to the lowest effective dose. I think there are some potential options.

Ross: This comes from Jane in Austin, Texas: “My 11-year-old daughter has what the doctors say is guttate psoriasis and has had it ever since she was eight years old. She recently has been diagnosed with chicken pox, and during this time her psoriasis has started to flare up. Is there anything I can do to make her more comfortable with the chicken pox while not making her psoriasis any worse?”

Dr. Yan: That's certainly a difficult situation where you have two things that can complicate one another. I think in this case, the guttate psoriasis certainly can be a challenge to treat, and there are certain things that can be helpful to keep that condition under better control. I think, first off, you certainly need to make sure that the flare isn't being triggered by a concomitant (accompanying) bacterial infection like strep, because strep can certainly aggravate the psoriasis. And then the Koebner phenomenon also is an important factor here because as the chickenpox flares that will tend to cause new areas of psoriasis to appear. If the chickenpox is diagnosed in a timely fashion, you can treat the chickenpox with appropriate antiviral medications.

And I think the general feeling is that when children develop chickenpox, it is a natural, self-limited condition that will go away on its own in the average child. We know that the psoriasis is likely to flare because of the chickenpox, and I would be more aggressive at treating the chickenpox up front so that we can keep the chickenpox under control so that it doesn't trigger more of the psoriasis. So I would use an antiviral to help shorten the overall course of the chickenpox.

And then you would want to try to do things that will make the skin feel more comfortable. And while we would tend to avoid topical steroids because there is a tendency for that to decrease the immunity in the skin, I think you can use other topical agents that can help reduce the itching and then reduce the scratching that will also aggravate the psoriasis. Things like pramoxine, which is found in a number of over-the-counter topical analgesics, helps reduce the pain and itching.

Ross: We got this from Teresa in New York, “How do I keep my son's skin hydrated? He plays and gets very dirty, so I need to bathe him a lot which dries out his skin. Any advice?”

Dr. Yan: I think that there are certain things that can be done. In kids who sweat a lot who feel the need to bathe more frequently will indeed dry out their skin because it tends to strip away those natural skin oils that are protective. And so you can use moisturizers more frequently. If you use them immediately after showers or baths, there is a sense that that tends to improve moisturizing of the skin, especially if you put it on within a few minutes after each bath or shower.

The other thing you can do is to keep those showers as short as possible, five minutes or less, to reduce the amount of drying effect on the skin. And then using a mild soap or cleanser, and there are a number of them out on the market ranging in things from the Dove for Sensitive Skin, Cetaphil, and various brands that are gentler on the skin that can be used for this purpose. So I would limit the amount of bathing and use mild cleansers, and more frequent emollient use on the skin. And if he doesn't like thick emollients, you can use something that's milder like a cream as opposed to an ointment and just have him use it frequently throughout the day to help reduce that drying effect.

And then finally there are certain moisturizing ingredients you can also look for, such as things that contain alpha hydroxy acid, ammonium lactate, or a small amount of urea. Small amounts of these ingredients can be used to help moisturize the skin a little bit more effectively as long as you don't have any open fissured areas, because if you have broken skin or open skin, these agents can also cause some irritation or stinging.

Ross: We are just about out of time, but before we go, is there anything that you would like to emphasize that we have talked about earlier in this hour or any questions or points that we didn't get to, Dr. Yan?

Dr. Yan: I would like to just emphasize that I think psoriasis is a manageable condition, and while it is a chronic disease, we can certainly find ways to help kids control their condition and manage their conditions hopefully to their satisfaction, and these can include agents that can be used safely with appropriate monitoring.

I also want children who have the condition to know that there are a number of support networks out there and that they shouldn't let their psoriasis define who they are because they have a lot of other things going for them aside from having this condition. They should take the opportunity to learn about this condition, and help educate others so that they can better understand it and make other people feel less stigmatized by their condition.

Ross: How do you educate others and not turn them off?

Dr. Yan: I think that that has to be done on a case-by-case basis. And some people are certainly more receptive to learning and being educated about it than others. I think that what bothers some of the families or some of the kids is that when they are out and about in the community at the supermarket or at a store that somebody will come up to them and make a comment or say something about it. And they may be well-intentioned or they may be less well-intentioned, but you can take that opportunity to then turn it around and ask them a question and say, “Well, it looks like you're curious about my skin or my child's skin. Do you want to know what that is and know a little bit more about it?” And keep the information session short, but give them enough information to know that this is what this is, that my child has psoriasis.

Or the child can take part and say, “I have psoriasis, and it is a skin condition that I have had for a while, and it's not contagious, and it is something that I treat with creams to help keep under control.” And if they can even make a small effort to doing that, I think it's very empowering for the kids and also helps to start that educational process for those who are willing to learn more about it.

Ross: Dr. Albert Yan, chief of pediatric dermatology at the Children's Hospital of Philadelphia, directs the pediatric dermatology fellowship training program. He has been honored by listings in the Consumer Research Council's Guide to America's Top Pediatricians and Guide to America's Top Physicians, Best Doctors in America, Consumers Checkbook Guide to Top Doctors, and Castle Connolly's America's Top Doctors. And now we understand why.